Application For A One-Time Transfer - Province Of Manitoba
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3SAMPLE APPLICATION FOR A ONE-TIME TRANSFER
Section 21.4 of The Pension Benefits Act of Manitoba and Sections 10.52 – 10.58 of the Regulation
NOTE: Administrators may use this sample to develop their own application form. It is a sample and is not a
prescribed form or form approved by the superintendent under the regulations. Administrators must ensure their form
complies with the requirements in subsection 10.56(4) of the regulation and that their form includes any additional
information they require to facilitate the transfer.
AN APPLICATION MAY ONLY BE MADE IN RESPECT OF A LIF OR LRIF THAT IS LOCKED-IN
UNDER THE PENSION BENEFITS ACT OF MANITOBA AND REGULATION
If you wish to make a One-time Transfer from LIFs, LRIFs or Pension Plans managed by different administrators, you
must make a separate application to each administrator
I - APPLICANT INFORMATION
___________________________________
______________________________________________________
First Name
Last Name
_________________________________________________________________________________________________
Address
________________________________
________________________
__________________
City
Province
Postal Code
_______/_______/_______
________________________
Date of Birth (Day/Month/Year)
Social Insurance Number
II - ADMINISTRATOR INFORMATION
_________________________________________________________________________________________________
Name of Administrator (Financial Institution or Pension Plan)
_________________________________________________________________________________________________
Address
_________________________________
_____________________
__________________
City
Province
Postal Code
□
□
Authorized Administrator:
YES
NO
If you are making a One-time Transfer from LIF(s), LRIF(s) or Pension Plan(s) managed by different administrators, you
must authorize one of those administrators to act as the Authorized Administrator and only the Authorized
Administrator will submit a Request to Superintendent of Pension for Written Notice.
III – ONE-TIME TRANSFER INFORMATION
Identify for each of your LIFs, LRIFs or Pension Plans:
•
Name of the Administrator
•
Address
•
Maximum amount that may be transferred from the plan
•
Amount to be transferred from each plan
•
Date the information was provided by the administrator
Application for a Prescribed Transfer from a LIF, LRIF or Pension Plan to a PRRIF
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